Identifying Data: Age, Gender, Occupation, and Marital Status

Please make this one on a 12 year old female with MONO, example provided COMPREHENSIVE SOAP NOTE RUBRIC Identifying Data: Age, Gender, Occupation, and Marital Status Source and Reliability:     Subjective: Chief complaint or appropriate health screening visit: The one or more symptoms or concerns causing the patient to seek care. Need not be the patient’s complete statement – may be a brief summary of reason patient wanted to be seen for this visit HPI: Complete subjective description of problem, including “OLDCARTS” findings or similar, including location, quality severity, duration, timing, context, modifying factors, associated signs/symptoms, relieving and aggravating factors, related systems. Medications, including OTC and Herbals Preparation Past Medical History:     Allergies – medications, food, environmental or seasonal     Childhood Illnesses – Chicken pox, Rheumatic fever, Rubella, Measles, and Mumps     Adult Illnesses         Injuries         Surgeries         Hospitalizations         Obstetric/Gynecologic         Psychiatric     Health Maintenance         Immunization status – DPT, MMR, Influenza, Hepatitis, Polio, and Pneumovax         Dental Exams (frequency and treatment)         Last eye exam (include results)         SBE/Pap/GYN (include results)         Testicular/rectal exam (include results) Family History: Include presence or absence of specific illnesses in family such as hypertension, diabetes, or cancer Personal and Social History:     Educational level     Personal interests     Lifestyle – exercise and diet     Older Adults – ADLs and iADLs Review of Systems: Pertinent positives and negatives in the differential diagnosis     Objective:         Vital Signs         Blood Pressure         Temperature                                                iii.      Pulse     Respirations     Height     Weight                                               vii.      BMI including normal, overweight, obese, morbidly obese     Physical Examination – specific systems as appropriate     Assessment and Plan (This section should process for the reader, should be based on current literature/guidelines. This should be organized and succinct.) Differential diagnoses including ICD – 10 and Rationale: List the other diagnoses that should be considered in light of the history and physical findings. Rationale: Articulate a rationale for the most likely diagnosis and for each differential diagnosis. In this discussion, include pertinent positives and pertinent negatives which help to rule out or rule in each diagnosis. Most likely diagnosis: (if more than one diagnosis, number each in order of priority) Include:     Pathophysiology of the problem     Explanation of the diagnosis     Diagnostic Testing     Lab testing     Radiology testing     Cardiac or Neurologic testing     Evaluations – Physical Therapy, Occupational Therapy, Speech Therapy, or Mental Health Evaluations     Medications and Treatments – pharmacological and non-pharmacological treatments. Should include at least 2 evidenced based references     Motivational Interviewing     References (APA Format) Topic Assignment status: Solved by our Writing Team at EssayCabinet.com   CLICK HERE TO ORDER THIS PAPER AT EssayCabinet.com GET THIS PAPER COMPLETED FOR YOU FROM THE WRITING EXPERTS NO PLAGIARISM